October 26, 2008

Placebo: makes everybody but ethicists happy

Happy lakeHalf of Doctors Routinely Prescribe Placebos - NYTimes.com refers to the paper Tilburt, Kaptchuk, et al. Prescribing "placebo treatments": results of national survey of US internists and rheumatologists, BMJ 2008;337;a1938. It seems that about half of the responding physicians prescribe placebo regularly, with over the counter analesics and vitamins as the most popular placebos (just 3% used saline and 2% sugar pills), with a worrying number of sedatives (13%) and antibiotics (13%). 62% thought the practice was ethically permissible.

Many medical ethicists are less keen on placebos, thinking the deception involved is bad for the physician-patient relationship since it may involve deception or lack of informed consent.

“Everyone comes out happy: the doctor is happy, the patient is happy,” said Dr. Emanuel, chairman of the bioethics department at the health institutes. “But ethical challenges remain.”

But given that placebos seem to have powerful effects, from a purely consequentialist position there might be good reasons to use them (as long as risky drugs or drugs likely to promote antibiotics resistance are not used). Researching ways of making placebo work better (and when it is actually worse than doing nothing) might be good value for money.

I wonder how many ethicists who are non-consequentialists, and how much the job security plays into their position. If you are a consequentialist you will relegate most issues to empirical research and at most weigh a few risks and benefits. If you are a non-consequentialist you will always have a chance to be the quoted dissenting opinion about any "advance", you will be able to invoke impressive ethics, defend the question from empirical study and always argue that there is a need for an ethicist on the committee. That ought to create a selection for non-consequentialist "yes, but..."-sayers in important positions even if people do not adjust their views for job security. On the other hand, the consequentialists fit in nicely with the formal rationality of health buraucracies, so their concerns are easier to implement than the more substantive rationality of non-consequentialists.

Posted by Anders3 at October 26, 2008 04:32 PM